Totally laparoscopic right hemicolectomy with transvaginal specimen extraction

We present our technique for totally laparoscopic right colectomy for locally advanced colon cancer with transvaginal specimen extraction. The patient was a 73-year-old female who presented with a biopsy proven cecal adenocarcinoma. We performed a right hemicolectomy using a 4 port approach with the patient in modified lithotomy position. Medial to lateral mobilization and early high ligation of the ileocolic pedicle were performed. The resected specimen was placed in a large retrieval bag. With the patient positioned in modified lithotomy, a posterior culpotomy was made and the specimen removed intact through the vagina. The culpotomy was closed from the vaginal approach. A 60mm stapled side-to-side anastomosis was created intracorporeally to complete the procedure. The specimen was 52cm in length and contained a 3.2cm tumor and 13 lymph nodes. The patient's pathologic stage was T3N1.

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Totally laparoscopic right hemicolectomy with transvaginal specimen extraction

Authors

S McKenzie, JH Baek, A Pigazzi

Abstract

We present our technique for totally laparoscopic right colectomy for locally advanced colon cancer with transvaginal specimen extraction. The patient was a 73-year-old female who presented with a biopsy proven cecal adenocarcinoma. We performed a right hemicolectomy using a 4 port approach with the patient in modified lithotomy position. Medial to lateral mobilization and early high ligation of the ileocolic pedicle were performed. The resected specimen was placed in a large retrieval bag.
With the patient positioned in modified lithotomy, a posterior culpotomy was made and the specimen removed intact through the vagina. The culpotomy was closed from the vaginal approach. A 60mm stapled side-to-side anastomosis was created intracorporeally to complete the procedure. The specimen was 52cm in length and contained a 3.2cm tumor and 13 lymph nodes. The patient's pathologic stage was T3N1.

Classification

clinical cases

Keywords

Totally laparoscopic right hemicolectomy, transvaginal specimen extraction

Media type

Surgical video

Duration

08'15''

Publication

2009-07

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E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2700.htm

Totally laparoscopic right hemicolectomy with transvaginal specimen extraction

1. Introduction 00'19''

We present our technique for totally laparoscopic right colectomy with transvaginal extraction. After dorsal lithotomy positioning and a standardized 4 port placement, the procedure begins with isolation of the ileocolic pedicle.

2. Ileocolic pedicle division 00'35''

The fold of Treves is grasped to elevate the ileocolic vessels, which are dissected at their base and transected with the vascular stapler.

3. Medial to lateral dissection 00'59''

The line of Toldt is reached through a medial to lateral dissection of the mesocolon off the retroperitoneum, being sure to identify and protect the duodenum.

4. Hepatic flexure mobilization 01'16''

The hepatic flexure is then mobilized through the gastrocolic ligament. The right colic branch is isolated and controlled with clips, allowing the remainder of the transverse mesentery to be divided with the Ligasure device.

5. Transverse colon transection 02'23''

The transverse colon is transected with an Endo-GIA stapler and the remainder of the right colon is sharply separated from the retroperitoneum and then an abdominal side wall.

6. Terminal ileum transection 02'58''

The terminal ileum and associated mesentery are transected with a vascular stapler. The specimen is placed in a large retrieval bag and placed in the pelvis. An assistant surgeon is positioned between the legs and exposes the posterior vaginal wall.

7. Culpotomy 03'45''

Under direct vision, the posterior culpotomy is made.

8. Transvaginal specimen extraction 04'08''

The retrieval bag is then passed through the culpotomy.

9. Culpotomy closure 04'51''

The culpotomy is closed via the perineum. A stay suture is used to align the two limbs of the anastomosis. Cautery is employed to develop paired enterotomies.

10. Side-to-side ileocolic anastomosis 05'28''

The transverse colon is engaged with the stapling device, followed by the ileum, and an antimesenteric side-to-side anastomosis is created using a 60mm stapler. The defect is closed with a two-layer sutured closure. The remaining mesenteric defect is positioned against the retroperitoneum and covered with omentum, which completes the procedure. Last, we see our patient with no visible extraction incision.